For the third year, the report ranked every county in the nation against others in its state. This year's rankings are based on 29 factors including premature deaths, smoking rates, teen births, children living in poverty and air quality.

“What the rankings tell us is that while access to medical care is critically important, our health is affected by much more than what happens in a doctor's office,” said Dr. Patrick Remington, associate dean of public health at the University of Wisconsin, lead author of the report. “They show us that where we live matters to our health.”

Despite Bexar County's rank in overall health — the report included 221 of the state's 254 counties — there were some big differences in various categories.

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For example, Bexar ranked 24th in medical care access and quality. But it ranked 215th for its physical environment — a broad category that includes air pollution, access to recreational facilities, availability of healthy foods and number of fast-food restaurants.

Dr. Thomas Schlenker, director of the Metropolitan Health District, was ambivalent about the report's value.

“I think the idea of rankings has limited usefulness,” Schlenker said. “I think it is legitimate to say that San Antonio is different than Dallas, Fort Worth and Houston and other metropolitan areas in Texas,” he said. “And I'm not really too surprised that we rank so low. Because we really do have some challenges here.”

Schlenker said it's more valuable to track whether San Antonio is making progress over time with critical problems such as teen pregnancy and sexually transmitted diseases, rather than compare itself to other communities.

Bexar County's overall rank has remained relatively steady over three years at 78, 71 and 73.

Surprisingly, some relatively poor Texas border counties ranked among the healthiest, including Zapata at 18th, Hidalgo at 21st and Webb at 26th.

“Wealth is correlated with good health, both among individuals and in communities,” Remington said. “But you do see exceptions. The border counties of Texas have quite high rates of poverty and low rates of education, but have some of the longest-living populations — obviously related to healthier lifestyles, close-knit families and social support.”

After Collin, the healthiest Texas counties were Williamson, Rockwall, Denton and Gillespie. Nearby Kendall and Comal ranked 6th and 7th.